肝动脉复流时机对大鼠肝内胆管上皮细胞缺血再灌注后超微结构的影响

目的 观察不同肝动脉复流时机对大鼠肝内胆管上皮细胞缺血再灌注损伤后超微结构的影响。方法 建立大鼠原位部分肝脏缺血再灌注损伤模型，54只大鼠随机分为假手术组（SO）、肝动脉先复流组（IAR）和门静脉先复流组（IPR），IAR组、IPR组分别于复流后0．5、2．0、4．0、12．0h时取材，用透射电镜观察肝内胆管上皮细胞的超微结构，通过计算机图像分析系统对线粒体形态计量分析。结果 （1）随着缺血再灌注后时间的延长，IAR组与IPR组肝内胆管上皮细胞损伤均有加重趋势，表现为线粒体肿胀、嵴模糊或消失、微绒毛减少等超微结构改变。（2）IPR 0．5h组、IPR 2h组胆管上皮细胞与IAR组相应时间点比较，超微结构损害无明显加重，线粒体平均面积、平均周径及数密度差异均无统计学意义（P〉0．05）；但IPR 4h组、IPR 12h组与IAR组相应时间点比较，超微结构损害加重，线粒体平均面积增大，差异有统计学意义（P〈0．05），线粒体平均周径增大，差异有统计学意义（P〈0．05），其中IPR 12h组线粒体数密度减少，差异有统计学意义（P〈0．05）。结论 与门静脉先复流相比较，肝动脉先复流对大鼠肝内胆管上皮细胞缺血再灌注后的超微结构具有保护作用。     

胆管上皮细胞分泌的VEGF-A在热缺血再灌注损伤后胆道及其微循环再生与修复中的作用

目的 探讨热缺血再灌注损伤后血管内皮生长因子-A(vascular endothelial growth factor-A,VEGF-A)在胆道及其微循环再生与修复中的作用,为积极预防和治疗胆道热缺血再灌注损伤导致的胆道并发症提供理论依据.方法 供受体均为雄性SD大鼠.供肝分别经历0 min(对照组)和10 min(实验组)热缺血后,进行重建肝动脉血供的大鼠肝移植模型.分别于供肝冷保存后(即0 h)以及术后6 h、24 h、3 d、7 d、14 d、30 d处死大鼠,收集标本.测定血清ALT、GGT、TBIL.免疫组化法检测VEGF-A表达情况.分别标记胆管上皮细胞、血管内皮细胞、增殖细胞,统计汇管区胆管数、血管数以及胆管上皮细胞增殖指数.原位杂交法检测VEGF-A mRNA表达情况.结果 实验组GGT和TBIL较对照组升高持续时间更长,术后30 d和14 d才降至正常.实验组汇管区胆管数及血管数均在术后14 d达到最高值,且明显多于对照组.肝细胞和血管内皮细胞VEGF-A、VEGF-AmRNA表达在术后24 h达到峰值后迅速下降,而胆管上皮细胞VEGF-A、VEGF-A mRNA表达持续升高,直到术后7 d才达到峰值.并且实验组表达水平均强于相应时间点对照组的表达.结论 热缺血再灌注损伤后.胆管上皮细胞合成和分泌VEGF.A增加,并且可能在促进胆管及胆管周围血管丛的再生中发挥重要作用.     

大鼠移植肝胆道系统不同部位异质性对缺血再灌注损伤耐受性差异的比较

目的 研究胆道系统不同部位胆管上皮细胞的异质性以及胆管周围血管丛构筑形式的不同,对缺血再灌注损伤耐受性的差异.方法 30只SD大鼠随机分成3组,Ⅰ组(假手术组),Ⅱ组(胆道缺血1 h再灌注1 h组),Ⅲ组(胆道缺血1 h再灌注2 h组).对肝门部胆管、胆总管近端及小叶间胆管的上皮细胞行凋亡(TUNEL法)检测、病理形态学评分和超微结构的定量分析.结果 Ⅱ组的细胞凋亡及病理形态评分在胆总管近端与小叶间胆管无统计学差异(P＞0.05),但肝门部损伤较重(P＜0.05);线粒体平均体积(V)及微绒毛面积密度(AMv)比较在肝门部最重,胆总管近端最轻(P＜0.05).在Ⅲ组以上各指标都表现为肝门部最重,小叶间胆管次之,胆总管近端最轻(P＜0.05).结论 胆管上皮细胞的异质性以及周围血管丛不同部位构筑形式的不同导致了胆道系统各部位损伤程度的差异.该结果为解释肝门部胆管狭窄高发率的临床表现提供了一定的实验基础.胆总管近端损伤最轻这一结果提示,在临床肝移植中,应尽量以胆总管近端作为最佳吻合部位.     

不同胆道灌洗方法对大鼠肝内胆管冷保存再灌注损伤的影响

目的观察不同胆道灌洗方法对大鼠移植肝肝内胆管冷保存再灌注损伤的影响。方法应用大鼠原位肝移植模型，将88只SD大鼠随机分为假手术组、胆道非灌洗组、UW液胆道灌洗组、生理盐水（NS）胆道灌洗＋UW液肝内胆道灌注保存组、HTK液胆道灌洗＋UW液肝内胆道灌注保存组、HTK液胆道灌洗＋HTK液肝内胆道灌注保存组。移植肝置于4℃林格液中保存2h后行原位肝移植。移植肝再灌注后24h，检测血清总胆红素（TB）、直接胆红素（DB）、碱性磷酸酶（AKP）、γ-谷酰转肽酶（GGT）及胆汁中GGT、葡萄糖（Glu）含量。在光镜及电镜下观察肝内胆管上皮细胞的形态学变化。结果与非灌洗组比较，胆道灌洗组术后各项指标明显改善（P〈0．01）；HTK液及NS灌洗组较UW液灌洗组术后指标改善明显（P〈0．05）。病理检测发现非灌洗组胆道损伤明显，各灌洗组胆道损伤程度明显改善，HTK液灌洗＋UW或HTK液灌注组对胆管上皮细胞的损伤较轻。结论移植肝冷保存前进行胆道灌洗可以明显减轻胆管上皮细胞的损伤，4℃HTK液灌洗＋4℃UW或HTK液灌注保存效果比较理想。     

门静脉、肝动脉同时灌注对供肝动脉缺血损伤的保护作用

目的探讨肝移植门静脉再灌注过程中肝动脉缺血(hepaticarteryischemia,HAI)损伤的严重性和应用肝动脉桥式置管(hepaticarterybridge-conduit,HABC)技术实现门静脉、肝动脉同时灌注对这一损伤的保护作用。方法32只犬按随机数字表法随机均分为4组:正常对照组、HAI30min组、HAI2h组和HABC组。后三组分别建立犬自体原位肝脏移植模型,HABC组应用HABC技术使肝动脉、门静脉同时再灌注。术后取供肝组织与胆管组织电镜观察肝细胞和胆管上皮细胞病理学改变。分别应用硫代巴比妥酸法检测肝组织中丙二醛(MDA)浓度、黄嘌呤氧化酶法检测过氧化物歧化酶(SOD)活性、酶标记法检测肝细胞线粒体琥珀酸脱氢酶(SDH)活性。结果HAI30min即可见供肝肝细胞和胆管上皮细胞水肿、线粒体嵴减少,HAI2h其病理改变进一步加重,胆管上皮尤为明显,而HABC组则见肝细胞和胆管上皮细胞比较完整,胆管上皮绒毛丰富。HAI30min组和HAI2h组肝组织中MDA含量增加,分别为(1.652±0.222)nmol/mgprot和(2.379±0.526)nmol/mgprot,而SOD则降低至(11.15±3.9)U/mgprot和(9.47±3.4)U/mgprot,SDH活性则分别降低至0.362±0.019和0.281±0.029,与正常对照组比较差异有统计学意义(P<0.05,P<0.01);而HABC组MDA含量、SOD和SDH活性与正常对照组比较差异无统计学意义(P>0.05)。结论HABC技术的实施,可为临床肝移植中预防HAI损伤,减少肝移植术后并发症,特别是胆道并发症的发生提供有效的方法。     

肝移植术后胆道并发症的预防和治疗

目的探讨肝移植术后胆道并发症预防和治疗。方法回顾性分析我院24例肝移植患者临床资料。结果3例患者通过MRCP和ERCP确诊为肝移植术后胆道并发症,经内镜微创治疗1例1年后死亡,2例随访2年仍健康存活。胆道并发症发生率为12.5%,没有与肝动脉相关胆道并发症发生。热缺血时间>5 min,冷缺血时间>12 h,胆道并发症发生率呈明显升高倾向。结论保存性损伤和缺血性损伤是肝移植术后胆道并发症的重要原因,修肝时肝外胆管的血供和警惕变异血管的存在,不放置T管和肝动脉、门静脉同步开放可显著降低胆道并发症。MRCP、ERCP和肝活检是早期诊断胆道并发症的主要手段,内镜微创和再次肝移植则是主要治疗措施之一。     

日本大耳兔胆道缺血再灌注损伤模型的建立

目的建立日本大耳兔胆道缺血再灌注损伤模型,用于肝移植术后胆道并发症及胆道损伤等研究。方法采用无损伤动脉夹联合胆总管及肝总动脉阻断制作胆道缺血模型,以假手术组(SO)及单纯肝动脉阻断组(HAO)作为对照,阻断时间分为2h和3h,各组分别于复流前、复流12h、1、2、3、7d取血测AST、ALT、TBA水平;取胆汁行胆汁TBIL、TBA、GGT测定。术后一周观察动物死亡情况;动物处死后取肝胆组织行石蜡切片HE染色光镜下观察。以单纯肝总动脉阻断组做对照。结果血清、胆汁指标和动物术后7d存活率联合阻断组与单纯肝总动脉阻断组相比差异显著,前者差于后者。随着缺血时间的延长,胆道损伤逐渐加重,病理改变由可逆性损伤转化为不可逆性损伤。结论联合胆总管及肝总动脉阻断胆道缺血再灌注模型胆道缺血完全,重复性好,复制简单,是较好的胆道缺血再灌注损伤模型。     

日本大耳兔胆道缺血再灌注损伤模型的建立

目的 建立日本大耳兔胆道缺血再灌注损伤模型，用于肝移植术后胆道并发症及胆道损伤等研究。方法 采用无损伤动脉夹联合胆总管及肝总动脉阻断制作胆道缺血模型，以假手术组(SO)及单纯肝动脉阻断组(HAO)作为对照，阻断时间分为2h和3h，各组分别于复流前、复流12h、1、2、3、7d取血测AST、ALT、TBA水平；取胆汁行胆汁TBIL、TBA、GGT测定。术后一周观察动物死亡情况；动物处死后取肝胆组织行石蜡切片HE染色光镜下观察。以单纯肝总动脉阻断组做对照。结果 血清、胆汁指标和动物术后7d存活率联合阻断组与单纯肝总动脉阻断组相比差异显著，前者差于后者。随着缺血时间的延长，胆道损伤逐渐加重，病理改变由可逆性损伤转化为不可逆性损伤。结论 联合胆总管及肝总动脉阻断胆道缺血再灌注模型胆道缺血完全，重复性好，复制简单，是较好的胆道缺血再灌注损伤模型。     

肝动脉缺血对犬自体移植肝和胆管超微结构的影响

采用自制的简易狗自体肝移植模型，观察肝动脉缺血(HAI)对移植肝和胆管超微结构的影响。结果发现：灌注后肝、胆细胞轻度水肿，线粒体基质疏松，嵴较模糊；HAI3小时，肝、胆细胞水肿明显加重，胞质疏松，线粒体扩大，嵴断裂或消失，部分空泡变异出现絮状电子致密斑，内质同明显扩张，核糖体解聚。表明HAI对供肝及胆管细胞有明显损伤作用。提示肝脏移植后HAI是某些并发症，特别是胆道并发症的重要致病因素之一。     

冷保存对肝移植术后肝内胆管微循环的影响

目的探讨供肝冷保存对肝移植术后肝内胆管微循环的影响。方法实验大鼠随机分为假手术组（SO组）、供肝冷保存1h组（CP1h组）、供肝冷保存24h组（CP24h组）。采用重建肝动脉的大鼠肝移植模型。在肝移植术后的不同时间点,观察肝内胆管组织损伤程度;经肝动脉注入微球,光镜下行肝组织汇管区内微球计数;采用间接免疫荧光双染技术检测肝组织汇管区微小血管内皮细胞eNOS、El＂-1和ICAM-1的表达,并采用原位杂交技术检测其mRNA的表达。结果冷保存再灌注可引起肝内胆管结构改变,冷保存时间越长损害程度越重。冷保存再灌注可引起肝组织汇管区内微球数量增加,且时间越长微球数量增加越明显。冷保存再灌注可引起汇管区微小血管内皮细胞eNOS蛋白及mRNA表达水平降低,而ET-1和ICAM-1的蛋白及mRNA表达水平升高。结论冷保存可引起大鼠移植肝脏肝内胆管微循环及其内皮细胞功能明显改变,微循环障碍可能在肝内胆管冷保存再灌注损伤中起重要作用。     

Predisposing factors for biliary complications following liver transplantation

INTRODUCTION: Biliary complications remain a major cause of morbidity and mortality in patients following liver transplantation. We sought to identify possible risk factors predisposing to biliary complications after OLT using duct-to-duct biliary reconstruction. MATERIALS AND METHODS: We retrospectively reviewed 5 years of prospectively collected donor and recipient data between April 1999 and April 2004. We evaluated the presence of biliary complications, donor and recipient age, cold ischemia time, hepatic artery thrombosis, non-heart-beating donor (NHBD), and graft steatosis (>30%). The results were compared with a control group of OLT patients without biliary complications. RESULTS: Among 173 OLT recipients, biliary complications occurred in 28 patients (16.2%), of whom 12 were leaks, 15 strictures, and 1 a nonanastomotic intrahepatic stricture. The mortality following biliary complications was 11%, compared to 6% in the control group. CONCLUSION: Biliary complications remain a persistent problem in OLT. Analysis of risk factors identified hepatic artery thrombosis and steatosis as predisposing factors. With greater experience, NHBD livers may also prove to be at greater risk of biliary complications.     

Retrograde reperfusion via vena cava lowers the risk of initial nonfunction but increases the risk of ischemic-type biliary lesions in liver transplantation – a randomized clinical trial

Initial nonfunction (INF) and biliary complications such as ischemic-type biliary lesion (ITBL) remain two major complications in clinical orthotopic liver transplantation (OLT). The influence of ischemia and reperfusion injury (I/R) as a significant risk factor for both complications is widely unquestioned. A new reperfusion technique that reduces I/R injury should lead to a reduction in both INF and ITBL. One hundred and thirty two OLT patients were included in this study and randomized into two groups. Group A underwent standard reperfusion with anterograde simultaneous arterial and portal reperfusion and group B received retrograde reperfusion via the vena cava before sequential anterograde reperfusion of portal vein and hepatic artery. Serum transaminase level as a surrogate parameter for I/R injury and serum bilirubin level as a parameter for graft function were significantly reduced during the first week after OLT in group B. INF rate was 7.7% in group A and 0% in group B (P = 0.058). ITBL incidence was 4.55% in group A versus 12.3% in group B (P = 0.053). Retrograde reperfusion seemed to be beneficial for hepatocytes, but was detrimental for the biliary epithelium. The unexplained increased incidence of ITBL after retrograde reperfusion will be focus of further investigation.     

原位肝移植术后胆道并发症治疗经验

目的总结原位肝移植术后胆道并发症的治疗经验。方法1999年2月至2004年2月,我中心采用胆总管-胆总管端端吻合术施行原位肝移植236例,96例采用置“T”管引流的胆管间断吻合;39例采用未置“T”管的胆管间断吻合技术;101例采用未置“T”管、前壁间断后壁连续的胆管吻合。结果全组术后32例(13·3%)发生胆道并发症,其中胆管狭窄24例(10·0%),胆漏6例(2·5%),胆管结石2例(0·8%)。3组胆道并发症发生率分别为17·7%、15·4%和7·9%,其中肝门部/肝内胆管狭窄发生率分别为8·3%,2·6%和1·0%。第3组胆道并发症发生率和胆管狭窄发生率显著降低(P<0·05)。20例胆管狭窄患者接受放射和/或内镜介入治疗,其中单纯吻合口狭窄治愈率90%,肝门部/肝内胆管狭窄治愈率60%。结论弃用“T”管的胆管前壁间断后壁连续的吻合方式能显著减少胆道并发症;非缺血相关性胆管吻合口狭窄和单纯肝门部胆管狭窄应首选介入治疗。     

Biliary complications after deceased-donor orthotopic liver transplantation

A wide range of potential biliary complications can occur after orthotopic liver transplantation (OLT). The most common biliary complications are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dyfunction, which may occur in up to 20%-40% of OLT recipients. Leaks predominate in the early posttransplant period; stricture formation typically develops gradually over time. However, with the advent of new techniques, such as split-liver, reduced-size, and living-donor liver transplantation, the spectrum of biliary complications has changed. Risk factors for biliary complications comprise technical failure; T-tube or stent-related complications; hepatic artery thrombosis; bleeding; ischemia/reperfusion injury; and other immunological, nonimmunological, and infectious complications. Noninvasive diagnostic methods have been established and treatment modalities have been modified towards a primarily nonoperative, endoscopy-based strategy. Besides, the management of biliary complications after OLT requires a multidisciplinary approach, in which interventional and endoscopic treatment options have to be weighed up against surgical treatment options. The etiology and spectrum of bile duct complications, their diagnosis, and their treatment will be reviewed in this article.     

Sequential versus contemporaneous portal and arterial reperfusion during liver transplantation

Although sequential portal and arterial revascularization (SPAr) is the most common method of graft reperfusion at liver transplantation (OLT), contemporaneous portal and hepatic artery revascularization (CPAr) has been used to reduce arterial ischemia to the bile ducts. The aim of this study was to prospectively compare SPAr (group 1; n = 19) versus CPAr (group 2; n = 21) among 40 consecutive OLT from heart-beating donors. There were no differences in the demographics characteristics, Model for End-stage Liver Disease scores, indication for OLT and donor parameters between the groups. OLT was performed using the piggyback technique. The biliary anastomosis was performed in all cases by a duct-to-duct technique with a T-tube in 32% versus 29% of cases without a T tube (P = .83). In the CPAr group, the liver was reperfused simultaneously via the portal vein and hepatic artery. CPAr showed a longer warm ischemia (66 ± 8 vs 37 ± 7 minutes; P < .001), while SPAr had a longer arterial ischemia 103 ± 42 vs 66 ± 8 minutes (P = .0004). Recovery of graft function was similar. There was no primary nonfunction and delayed graft function occurred among 10% versus 9%. Liver function tests were similar between the two groups up to 90 days case of follow-up- One-year graft and patient survivals were, respectively, 89% and 95% versus 94% and 100% (P = .29). At a median follow-up of 13 ± 6 versus 14 ± 7 months, biliary complications included anastomotic stenoses in 15% versus 19% (P = .78) and intrahepatic non-anastomotic biliary strictures in 26% versus none (P = .01) for SPAr and CPAr, respectively. CPAr was safe and feasible, reducing the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia to the intrahepatic bile ducts.     

Correlation between graft arterial anatomy and biliary complications after liver transplantation

Knowledge of the arterial vascular anatomy of the liver is important for orthotopic liver transplantation (OLT) because the lack of an adequate arterial blood supply results in biliary and parenchymal complications or graft loss. A number of reports have shown a relationship between aberrations of graft arteries and an increased incidence of early or late complications. Recent studies suggest no differences unless multiple anastomoses are required. The aim of this study was to report the incidence of aberrant hepatic arterial anatomy and its impact on vascular and biliary complications. We retrospectively reviewed data of 90 OLT performed on 82 patients, including 4 who underwent retransplantation from March 2003 to March 2006. The means recipient age was 52.47 years and 49 were men. The main caval vein reconstruction technique was piggyback (n = 55; 61.2%). The biliary reconstruction was performed by an end-to-end choledocho-choledocho anastomosis in 83 cases (92.3%) with choledocho-jejunal anastomosis (Roux-in-Y) in 7 cases (7.7%). Aberrant arterial anatomy was noted in 20 liver grafts (22.2%), namely, accessory right hepatic artery (n = 6; 6.6%), accessory left (n = 10; 11%), both accessory right and left (n = 3; 3.3%), and hepatic common artery from mesenteric artery (n = 1; 1.1%). Among the transplantations of grafts with aberrant arterial anatomy, 2 cases (10%) developed hepatic artery thrombosis (HAT) and 4 (20%) biliary complications. The rate of HAT and biliary complications among grafts with normal arterial anatomy was 3 and 8 cases (4.2% and 11.42%), respectively. Despite a greater number of complications among OLT with aberrant arterial anatomy, the Fisher test showed no significant relationship between HAT or biliary complications and aberrant arterial anatomy.     

Late biliary complications in pediatric liver transplantation

PURPOSE: The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children. METHODS: The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge. RESULTS: Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001). CONCLUSIONS: Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.     

肝移植术后胆管非吻合口狭窄的病因分析

目的探讨肝移植术后胆管非吻合口狭窄的成因及分类,寻找胆管非吻合口狭窄的防治方法。方法回顾性分析2000年5月至2005年12月5年间381例次(373例)肝移植患者的临床资料,其中20例患者术后发生胆管非吻合口狭窄,随访时间5～71个月。结果20例胆管非吻合口狭窄患者中,肝内外弥漫型狭窄6例,肝外局限型狭窄者14例,胆管非吻合口狭窄发生率5.25% (20/381),所有患者均经T管造影、ERCP或MRCP确诊。6例患者弥漫型狭窄的原因为:肝动脉血栓形成1例,供肝未进行有效胆道冲洗3例,腔静脉吻合口出血行再次吻合(致使胆道二次热缺血时间超过3 h)1例,不明原因1例。14例局限型狭窄的原因为:变异血管损伤2例,其他原因可能为冷热缺血时间过长、肝门解剖过度及供肝获取方法不当等。结论肝移植术后胆管非吻合口狭窄原因复杂,最主要的原因包括胆管的血供损伤、胆管的二次热缺血时间延长、供肝胆管是否及时有效的冲洗以及合理的取肝方法。     

Outcome of partial reconstruction of multiple hepatic arteries in pediatric living donor liver transplantation using left liver grafts

Partial liver grafts used in living donor liver transplantation (LDLT) may have multiple hepatic artery (HA) stumps. This study was designed to validate the safety of partial reconstruction of multiple HAs in pediatric LDLT cases. From January 2000 to June 2014, 136 pediatric LDLT recipients were categorized into three groups: single HA group (Group 1, n = 74), multiple HAs with total reconstruction group (Group 2, n = 23), and multiple HAs with partial reconstruction group (Group 3, n = 39). Partial reconstruction was performed only when there was pulsatile back‐bleeding after larger HA reconstruction and sufficient intrahepatic arterial flow was confirmed by Doppler ultrasound (DUS). There was no significant difference in biliary complication rate, artery complication rate, patient survival, and graft survival among these groups. Risk factor analysis revealed that the presence of multiple HAs and partial reconstruction of multiple HAs were not risk factors of biliary anastomosis stricture. In conclusion, partial reconstruction of HAs during pediatric LDLT using a left liver graft with multiple HA stumps does not increase the risk of biliary anastomosis stricture or affect graft survival when intrahepatic arterial communication is confirmed by pulsatile back‐bleeding and DUS.     

Simultaneous surgical repair for combined biliary and arterial stenoses after liver transplantation

After orthotopic liver transplantation (OLT), hepatic artery stenoses (HAS) and biliary strictures (BS) are frequent. These complications remain a significant cause of graft loss and patient death. The present study reported a group of 7 patients in whom both HAS and BS were identified and treated surgically in the same surgical session. The median times to diagnosis were 42 (range, 5-120) and 84 (range, 15-280) days after OLT for biliary and arterial stenosis, respectively. The mortality was nil. Two patients (28%) developed postoperative complications. The median hospital stay was 16 days (range, 10-42). All patients are alive; there was no graft loss. With a median of 76 months' follow-up (range, 38-132), only 1 patient (14%) developed recurrence of both BS and HAS. In patients with coincident biliary and artery stenosis, concomitant surgical repair is feasible, offering good long-term results.